If you are a family member, family member s dependent, family member s spouse, etc. : B. If you are a family member, family member s dependent, family member s spouse, etc. : c. If you are a family member, family member s dependent, family member s spouse, etc.: ? Section 1 (b): ? Contract Holder s Signature: Yes : Yes No : C. If your family member s name was different from the contract holder s : Name: : Please make an adjustment in the “Correct Name” box: D. Sign the front page of the contract under the heading : “Change of name and address” or “Change of Address to my residence” or “Change of address” D. Sign the two forms enclosed A. Contract Holder s Signature (Signs 1 and 2): Yes Yes No : E. Contract Holder s Signature (Signs 3 and 4): Yes Yes No : F. Contract Holder s Signature (Signs 1 and 2, and signatures of two witnesses (Signatures of witnesses 1 – 2). (The witnesses must appear in person to authorize contract, and should complete forms A and B, with the witness also signing the contract). Yes Yes No : G. Contract Holder s Signature (Signs 3 and 4, and signatures of two witnesses (SIGNATURES OF WITNESSES 1 – 5). (The witnesses must appear in person to authorize contract) Yes Yes No : H. Contract Holder's Signature (Signs 5 and 6): Yes Yes No : I. Contract Holder's Signature (Signs 3 and 4, and signatures of two witnesses (SIGNATURES OF WITNESSES 1 – 5, but does not address the signature issue) Yes Yes No : J. Contract Holder's Signature (Signs 5, 6 and 7): Yes Yes No (This item must be completed on contract. All signatures must be in original form. The witnesses must also be present, must be in handwriting) : K. Notice of Intent to Commit a Fraud (Note this section should appear in the contract under “Notice of Intent to Commit a Fraud”): Yes Yes No : L. Signature of Contract Holder (Note this item must appear in the contract under “Signature: (signature of witness)”): Yes Yes No : M. Signature of Contract Holder (Note this item should appear in the contract under “Signature of witness(signature of witnesses)”): Yes Yes No : N.
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INDIVIDUAL CHANGE FORM FOR AWARE CARE, OPTIONS BLUE, SIMPLY BLUE AND MSA Instructions: Please check the appropriate box and answer all questions relating to the change you'd like to make. For prompt
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The individual change form is used to report and request changes to personal information.
Who is required to file individual change form for?
Any individual who needs to make changes to their personal information is required to file the individual change form.
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To fill out the individual change form, you need to provide accurate and updated information in the designated fields.
What is the purpose of individual change form for?
The purpose of the individual change form is to ensure that individuals' personal information is kept up-to-date and accurate.
What information must be reported on individual change form for?
The individual change form typically asks for details such as name, address, contact information, and any other relevant personal data that needs to be updated.
When is the deadline to file individual change form for in 2023?
The deadline to file the individual change form for 2023 will be determined by the relevant authorities and announced accordingly.
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The penalty for the late filing of the individual change form may vary depending on the regulations and policies set by the governing body.
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